Healthcare Provider Details

I. General information

NPI: 1104040658
Provider Name (Legal Business Name): MICHAEL BERGQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 E 4000 S
SALT LAKE CITY UT
84124-1446
US

IV. Provider business mailing address

1321 E 4000 S
SALT LAKE CITY UT
84124-1446
US

V. Phone/Fax

Practice location:
  • Phone: 801-560-0943
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number289291-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: